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March 13, 2019

Media Statement on Behalf of Ed Lamb

Mount Carmel continues to take significant steps after the deaths of patients under the care of Dr. William
Husel to chart a new path for the Intensive Care Unit (ICU) at Mount Carmel West. We have great confidence
in our colleagues and our leadership, however, we understand that these events likely lead the communities
that we serve to wonder what allowed this situation to develop and persist. As a result of our investigation and
to address these concerns, and without passing judgment on our clinicians, we have taken a number of steps
to ensure that our patients and our communities can be confident that we are doing everything possible and
that they can continue to trust Mount Carmel to provide extraordinary people-centered care that is safe.

To that end, we have:

 Appointed new interim clinical leadership for Mount Carmel West as a whole, as well as new leadership
in key areas of the ICU at Mount Carmel West—our previous physician, nursing and pharmacy leaders
are on administrative leave;
 Removed from patient care any colleague who was in any way part of medication administration for an
impacted patient;
 Provided information to appropriate licensing boards on all colleagues who were in any way part of
medication administration for an impacted patient; and
 Continued our internal investigation and active cooperation with all relevant authorities and regulatory

New interim clinical leadership

We have identified new interim clinical leaders for Mount Carmel West and our ICU. Our previous physician,
nursing and pharmacy leaders are on administrative leave while we complete our internal investigation.

Employment status and reporting to licensure boards

We have identified a total of 48 nurses and pharmacists whose actions are under review and whose names
have been reported to the relevant nursing and pharmacy boards. Out of an abundance of caution, we have
removed all colleagues who were associated with medication administration for an impacted patient. In total,
30 colleagues are on administrative leave, and 18 no longer work for Mount Carmel—many of whom left years

Placing colleagues on administrative leave does not reflect final judgment on their actions. It is the appropriate
step to take while we continue our internal investigation. All of our actions to date—including colleague
decisions—were based on the information we had available at the time. Given the ongoing nature of the
investigation, these actions may change as new information becomes available.

We also want to emphasize that colleague actions are being thoroughly reviewed on a case-by-case basis.
After a thorough review of each colleague through our fair and just culture process, we anticipate some
colleagues may return to work at the appropriate time.
March 13, 2019

Building Upon Actions Already Announced

The actions shared today build on many already put in place to ensure changes throughout our system to
guard against the improper actions that may have led to the deaths of patients. Those include:
 Adding a new protocol to set maximum appropriate doses for pain medication in our electronic medical
record system;
 Implementing a new escalation policy for deviations in our pain medication protocols;
 Restricting the ability to bypass pharmacy review of medication orders;
 Increasing clinician education on standards and practices regarding end-of-life care;
 Initiating a review of our culture of safety initiative to identify what needs to change;
 Implementing numerous other initiatives to ensure patient medication safety; and
 Engaging independent experts who are assisting us with this process.

We are committed to understanding how this happened and ensuring it can never—and will never—happen
again. The steps we have taken—and may take in the future—are all a reflection of this commitment.

What’s Next
Mount Carmel and Trinity Health’s integrated team will continue to work together to implement meaningful
change. We are driven to do this by a responsibility to live our mission and do what’s right—both for our
patients and for our colleagues.

We will continue to do everything needed to ensure that patients can continue to trust Mount Carmel Health
System and Mount Carmel West for safe, high-quality care—just as they have for 130 years.